Mindfulness-based interventions for co-occurring mental ...Cape Cod Symposium on Addictive Disorders Hyannis, MA September 13, 2014 Mindfulness-based interventions for co-occurring

Carl Fulwiler, MD, PhD

Director, Systems and Psychosocial Advances Research Center Department of Psychiatry

University of Massachusetts Medical School

Cape Cod Symposium on Addictive Disorders Hyannis, MA

September 13, 2014

Mindfulness-based interventions for co-occurring mental health

and addictive disorders

ASAM Disclosure of Relevant Financial Relationships

27th Annual Cape Cod Symposium on Addictive Disorders

Presentation: Mindfulness-based interventions for co-

occurring mental health and addictive disorders

9/13/14

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What is mindfulness and how is it used in treating mental disorders and addiction?

How does it work?

Overview of the core elements of MBCT & MBRP and how they differ

Emotion dysregulation in mental health and addictive disorders

Emotion regulation deficits

• Mood and anxiety disorders, borderline and antisocial personality disorders, PTSD, alcohol and drug use disorders

• Nearly 200 DSM diagnoses involve emotion dysregulation

Werner & Gross (2009) In Kring & Sloan (Eds) Emotion Regulation and Psychopathology. Guilford , NY

Fad or breakthrough?

Habits of mind and behavior

Auto-pilot

Past Future

Multi-tasking

A definition of Mindfulness

The awareness that emerges from paying attention

on purpose and non-judgmentally

to the unfolding of experience from moment to moment

Adapted from Jon Kabat-Zinn, 2003

Mindfulness = Focused Attention + Open Monitoring

Focused attention – directing and sustaining attention on a chosen object, noticing when mind wanders – disengaging and redirecting to object of attention

Open monitoring – non-directed, non-reactive moment to moment awareness of all aspects of experience

Lutz, et al Trends in Cognitive Sciences 2008

Models of clinical interventions

Dialectical Behavior Therapy (DBT) and Acceptance and Commitment Therapy (ACT):

• CBT-based with training in mindfulness skills

• Mindfulness one component among several

• Guided exercises vs. formal meditation

Models of clinical interventions

Dialectical Behavior Therapy (DBT) and Acceptance and Commitment Therapy (ACT):

• CBT-based with training in mindfulness skills

• Mindfulness one component among several

• Guided exercises vs. formal meditation

Practice is at the core of MBSR, MBCT, MBRP:

• Teaching formal meditation practices

• Daily practice 30-45 min.

• Teachers have extensive personal practice & formal training in retreat setting

Mindfulness-Based Stress Reduction

JAMA Intern Med. 2014 Jan 6. doi: 10.1001/jamainternmed.2013.13018

Goyal et al. 2014 – Methods

•Databases searched: MEDLINE, PsycINFO, EMBASE, PsycArticles, Scopus, CINAHL, AMED, Cochrane Library

•Tools used: Systemic review software; random-effects meta-analyses using standardized mean differences (effect size [ES]; Cohen d)

•Only included RCTs with active control groups

•Excluded studies in which meditation was not the foundation – yoga, tai chi, ACT, DBT

•18, 753 citations title-abstract reviewed, 1,651 full-text articles reviewed - 47 trials (N=3515) met inclusion/exclusion criteria

Goyal et al. 2014 – Results

Mindfulness meditation programs had moderate evidence of improved anxiety, depression and pain

Outcome 8 weeks Range 3-6 mos Range

Anxiety 0.38 [0.12-0.64] 0.22 [0.02-0.43]

Depression 0.30 [0.00-0.59] 0.23 [0.05-0.42]

Pain 0.33 [0.03- 0.62]

Goyal et al. 2014 – Results

Mindfulness meditation programs had moderate evidence of improved anxiety, depression and pain

Outcome 8 weeks Range 3-6 mos Range

Anxiety 0.38 [0.12-0.64] 0.22 [0.02-0.43]

Depression 0.30 [0.00-0.59] 0.23 [0.05-0.42]

Pain 0.33 [0.03- 0.62]

• Insufficient evidence of effect on substance use* •No evidence mindfulness better than active treatment

(drugs, CBT and other behavioral therapies)

Mindfulness-based cognitive therapy for depression

Depression

• The leading cause of disability in the U.S. for ages 15-44

• 2nd leading cause of disability worldwide

WHO The Global Burden of Disease, 2008

NIMH Statistics, http://www.nimh.nih.gov/statistics/1MDD_ADULT.shtml

Depression treatment outcomes and recurrence

Majority have incomplete response, non-response, recurrence, or drop out of treatment

With each recurrence likelihood of future recurrence increases

Alternatives to long-term antidepressant medication?

Emotional reactivity and Relapse

Segal et al. (2006) Archives of General Psychiatry

12/40 = 30%

32/47 = 68%

Survival Analysis

Improved depressive symptoms

and quality of life

Godfrin & van Heeringen , Behaviour Research and Therapy 48, Iss 8 2010 738 - 746

Controls

MBCT

27% 28%

71%

Segal Z, et al. Arch Gen Psychiatry. 2010 Dec: 67(12):1256-64

Emerging evidence for efficacy of MBCT for current episodes of depression

Geschwind 2012 Br J Psychiatry – N = 130 randomized to MBCT vs. TAU – Reduction in depression scores greater with MBCT:

30-35% improvement vs. 10%, p<.001

van Aalderen 2012 Psychol Med – Subjects with recurrent depression randomized to

MBCT+TAU (n=102) or TAU alone (n=103) – MBCT as effective for patients who were currently

depressed as for patients who were in remission

Addiction like major depression – a chronic, relapsing condition

Mindfulness-Based Relapse Prevention (MBRP)

• Mindfulness practices with relapse prevention skills training

• Patterned after Mindfulness-Based Cognitive Therapy (Segal et al. 2002)

• Group format, 8 weekly 2-2.5 hr. sessions

• Daily home practice w/ CD

• Aftercare or post-detoxification/stabilization

Goals of MBRP

• Increased awareness of triggers and habitual responses

Goals of MBRP


• Cultivate present moment awareness and skillful responses to decrease likelihood of relapse

Goals of MBRP



• Observe unpleasant thoughts and feelings and accept them without judgment

Goals of MBRP




• Change our relationship to discomfort, learning to recognize challenging emotional and physical experiences and responding to them in skillful ways

Goals of MBRP




• Change our relationship to discomfort, learning to recognize challenging emotional and physical experiences and responding to them in skillful ways

• Build a lifestyle that promotes mindfulness practice and recovery

Research on MBRP – Populations studied

• Adults in outpatient treatment

• Adults who recently completed detox or intensive outpatient treatment

• Incarcerated adults with a history of substance abuse

• Smokers

Research on MBRP: First RCT – Pilot feasibility study (Bowen et al 2009)

Bowen,S., et al. (2009) Subst Abus. 2009 ; 30(4): 295–305

• N=168 from community treatment facilities • Avg. age 40; 71.5% male; 42.1 % ethnic/racial minority • MBRP vs. RP post-intervention (detox or IOP) vs. TAU • Pre-post, 2 and 4 month outcomes • 54% reporting regular meditation practice at 4-month

follow-up – 4.7 d/wk, 30 min/session • 4 month outcomes: • days of use 2.1 vs. 5.4 (p = .02)

Research on MBRP: Full-scale RCT (Bowen 2014)

• RCT N=286 from community treatment facilities • Avg. age 40; 71.5% male; 42.1 % ethnic/racial minority • MBRP vs. RP post-intervention (detox or IOP) vs. TAU • 6 and 12 month outcomes

Bowen,S., et al. (2014) JAMA Psychiatry 71(5):547-556

Research on MBRP: Full-scale RCT (Bowen 2014)

6 months:

• MBRP & RP significantly longer time to first drug use and heavy drinking (vs. TAU)

• Significantly fewer days of drug use

12 months:

• MBRP significantly fewer days of drug use (vs. RP/TAU)

• Significantly lower probability of heavy drinking

* Self-report largely confirmed by drug screens

Bowen,S., et al. (2014) JAMA Psychiatry 71(5):547-556

Common elements of MBSR/MBCT/MBRP

Switch out of: • Automatic pilot

• Avoidance

• Thinking about

• Judging and fixing

• Reactivity

• Unhealthy habits

To: •Awareness; Intentional mode

•Curiosity and acceptance

•Directly experiencing

•Non-doing and being

•Skillful responding

•Taking care of ourselves and staying well

Common elements

Class structure: • Guided practice • Inquiry • Worksheets, handouts, homework

Teaching style: • Embodied mindful presence – awareness,

acceptance, compassion – reflects personal practice • Experiential teaching emphasizes investigating

experience directly • Inquiry focuses on present-moment experience vs.

story-telling and interpretation

Common elements of MBSR/MBCT/MBRP Common elements of MBSR/MBCT/MBRP

Inquiry This requires the instructor to sharpen his/her ability to listen closely, allow space, refrain from the impulse to give advice, and instead, to inquire directly into the actuality of the participant’s experience.” Jon Kabat-Zinn, Santorelli 2005

NOTICING: Observing the direct experience

DIALOGUE: Exploring the effects of bringing awareness to direct experience

LINKING: Exploring how these learnings relate to ways of being with inner and outer experiences in daily life

Three layers of inquiry (Crane, R. 2009)


Formal practices:

• Body scan

• Mindful movement/yoga

• Walking meditation

• Mindfulness of breath/body/sounds/thoughts

Informal practices:

• Mindfulness of daily activities

• Moment to moment awareness


Practice, practice, practice – Formal meditation practice mediates improvement

Carmody & Baer (2008) J of Behav Med

Cultivating awareness of the link between activity and mood

Excessive focus on work or other stressors, gradually giving up of activities that we enjoy and nourish us, depletes our energy and resources and leaves us vulnerable to

relapse

Segal, Williams and Teasdale 2013 (adapted from M. Asberg)

1. Awareness and automatic pilot

2. Living in our heads

3. Gathering the scattered mind

MBCT Sessions

Developing

Awareness




4. Recognizing aversion

5. Allowing and letting be

6. Thoughts are not facts

MBCT Sessions

Developing

Awareness

Turning toward

the unpleasant




4. Recognizing aversion

5. Allowing and letting be

6. Thoughts are not facts

Day of practice

7. How can I best take care of myself?

8. Maintaining and extending new learning

MBCT Sessions

Developing

Awareness

Turning toward

the unpleasant

Staying well,

taking action

when mood is

low

MBRP Sessions

1. Automatic pilot and relapse

2. Awareness of triggers and craving

3. Mindfulness in daily life

Awareness

MBRP Sessions




4. Mindfulness in high-risk situations

5. Acceptance and skillful action

6. Seeing thoughts as thoughts

Awareness

Mindfulness

& relapse,

acceptance

MBRP Sessions




4. Mindfulness in high-risk situations

5. Acceptance and skillful action

6. Seeing thoughts as thoughts

Day of practice

7. Self-care and lifestyle balance

8. Social support and continuing practice

Awareness

Mindfulness

& relapse,

acceptance

Staying well

Informal practices

MBCT:

• 3 step breathing space

• 3 step breathing space with difficulty

MBRP:

• S.O.B.E.R. breathing space

• Urge surfing

S.O.B.E.R. Breathing space

S Stop: pause wherever you are

O Observe: what is happening in your body & mind

B Breath: bring focus to the breath as an ‘anchor’ to help you focus and stay present

E Expand awareness: to your whole body & surroundings

R Respond: mindfully vs. automatically

Integrating Mindfulness and 12 Steps


Admitted we were powerless over alcohol…

Awareness that we are suffering – that we are the cause of our own suffering and have caused suffering in others




Came to believe that a Power greater than ourselves could restore us to sanity

Accessing deep inner sources of wisdom that we share with all beings




Came to believe that a Power greater than ourselves could restore us to sanity

Accessing deep inner sources of wisdom that we share with all beings

Decided to turn if over to a higher power

Letting go of delusions of control, following a wisdom path with an ethical foundation of generosity, compassion and loving-kindness

How does it work?

Meditation experience is associated with increased cortical thickness in specific areas

Lazar et al. NeuroReport, 16, 1893-97, 2005

R. anterior insula

Somato-sensory cortex

Brodmann area 9/10

8-week MBSR training results in lasting changes in the brain

Davidson, et al. Psychosomatic Medicine 65(4):564-70, 2003

4 months Before

Sadness provocation

elicits:

a) neural activation in

midline self-referential

processing areas,

b) deactivation in

visceral & somatic

processing areas

Mindfulness training reduces neural reactivity

Reduced

deactivation

(red = MT > control)

Farb et al., 2010

Reduced

activation

(blue = Control > MT)

Emotion regulation pathways

Resting state fMRI provides a measurement of functional brain connectivity

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Correlation between seed ROI and other voxels

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Seed ROI

Amygdala-orbitofrontal functional connectivity is inversely related to trait differences in anger

Fulwiler, Zhang and King 2012, Neuroreport 23(10):606-10

MBSR training changes amygdala functional connectivity

Second sample: increased amygdala-prefrontal and amygdala-insula connectivity

Anterior Insula

Dorsolateral PFC

Insula

Conclusions

• To deliver a mindfulness-based intervention with fidelity, the teacher/therapist should have their own practice

Conclusions


• Rigorous clinical trials have demonstrated the effectiveness of mindfulness for depression, anxiety and prevention of relapse to addictive disorders

Conclusions



• Improved emotion regulation achieved through sustained meditative practice depends on changes in the brain’s emotion regulation circuitry

Conclusions



• Improved emotion regulation achieved through sustained meditative practice depends on changes in the brain’s emotion regulation circuitry

• A mindfulness approach is compatible with the 12 steps

Additional information

MBSR UMass Center for Mindfulness umassmed.edu/cfm

MBCT Oxford Mindfulness Center oxfordmindfulness.org

Mindfulness-Based Relapse Prevention mindfulrp.com

Professional training in MBCT and MBRP

• UCSD Professional Training Inst. mbpti.org

• Omega Inst., Rhinebeck NY eomega.org

12 steps and Mindfulness

• Kevin Griffin kevingriffin.net • Thérèse Jacobs Stewart mindroads.com • Buddhist Recovery Network buddhistrecovery.org

Questions? [email protected]

Copy of presentation: umassmed.edu/sparc ->

Publications and Products -> Presentations -> Wellness

http://www.umassmed.edu/ PageFiles/39837/MindfulnessBasedInterventions.pdf

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Mindfulness-based interventions for co-occurring mental ...Cape Cod Symposium on Addictive Disorders Hyannis, MA September 13, 2014 Mindfulness-based interventions for co-occurring